EMS Protocol of the Week - Eye Injuries (Adult and Pediatric)

Another trauma protocol for you all this week, and this one…

is…

…a sight for sore eyes…? 

The approach to eye injuries, like all other trauma protocols, is built around ABCs and transport. Specific considerations for the eye run in parallel to those for abdominal injuries: if the eye’s out, don’t put it back in, and if there’s something sticking out of it, just stabilize it rather than try to remove it. Otherwise, irrigation is the primary intervention CFRs and EMTs have in their arsenal. Paramedics, you may be interested to learn, do in fact have topical anesthetics (proparacaine or tetracaine) that they can give to assist with transport, but again, they will otherwise be focused on bringing the patients to your capable hands.  

Protocols, protocols everywhere! As far as the…eye…can see! Okay I’m done. www.nycremsco.org and the protocol binder for more.

Dave

EMS Protocol of the Week - Abdominal Injuries (Adult and Pediatric)

Very straight forward approach to abdominal injuries this week. EMS will assess and support ABCs from the CFR level and dress any eviscerations (without replacing any protruding organ), and BLS will initiate transport.

That’s it! Not much to worry about from an OLMC perspective, although now you know what to say if anyone calls asking if they should shove some loops of intestine back into the abdominal cavity (no, they should not).

See you all next week! All this and more at www.nycremsco.org and the protocols binder!

Dave

POTD: Mindfulness

Have any of you ever read the EMRA Wellness guide? If your experience was anything like mine, I vaguely remember getting an EMRA box at the start of residency full of goodies and a ton of these little reference books. This is what I saw when I opened the box:

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcT80v8paanyyxRdN9EH9OxL7AMEZYNebVu7TQ&usqp=CAU

I remember thinking how handy these books were, that I was going to read each of them one by one to study from....until I opened the first one on antibiotics, became completely overwhelmed as a novice intern, and put them all away for the day.

One of the books I must have skipped over was the EMRA Wellness guide. I remember encountering a particularly rough month in my intern year, and began mindlessly googling information about emergency medicine wellness, to see how other, smarter people than I have learned to deal with the stressors of my future career. And that's when I found the digital edition of the wellness guide- and saw a very familiar name on the booklet:

( https://www.emra.org/books/emra-wellness-guide/cover/ , also comes as a free app you can download)

Geeking out when I recognized the name, I started reading. It's full of great, evidence-based knowledge and resources designed to understand and combat the stressors unique to EM physicians. One of the things that really stuck out to me was the chapter on mindfulness, and is the one I often recall on a busy shift.

What is mindfulness?

Mindfulness is "the basic human ability to be fully present, aware of where we are and what we're doing, and not overly reactive to or overwhelmed by what's going on around us." It is done by taking in the moment, intentionally, and without judgement. It is a method of quieting the mind by focusing on things one moment at a time, free from "the combinations of judgements, desires, and assumptions whispered by your inner voice." We practice mindfulness when we meditate, do body scans, and enjoy mindful moment practices. It's like hitting the pause button, taking in what you're sensing and feeling in that moment, accepting it, and responding without immediate reaction to a stimuli. 

Why practice mindfulness?

Practicing mindfulness helps in the moment and long term. In the short term, it quiets the mind, allowing you to put some space in between yourself and your actions, and gives us a chance to ground ourselves in the current moment. In the long term, mindfulness becomes less difficult and strange: you naturally may find yourself handling daily stressors better, staying calmer, and being able focus better without the constant brain chatter that exists in the reactive mind. Additionally, practitioners of mindfulness report improved insight into their personality and emotions, have deeper appreciation of the good things over the bad in their lives, and find themselves becoming less overwhelmed. Mindfulness can be practiced anywhere, does not take long, and trains your brain to react to stressors better after sustained practice.

What is the evidence?

The EMRA guide describes a few studies. In the first, volunteers were placed in an MRI scanner while being asked to focus their attention on the sensation of breathing. They were asked to hit a button if they felt their mind wandering, and then refocus their attention on the cycle of their breathing. The four phases identified were described as the cognitive cycle: mind wandering, then becoming aware of distraction, reorienting attention, and resumption of focused attention, where each corresponded to a different part of the brain activated and detected by MRI. Those more experienced at meditating simultaneously showed increased activity in the brain centers corresponding to increased attention and focus, but paradoxically had less activation, suggesting a continued state of meditation allowed subjects the ability to focus more but with less effort.

Additional studies showed that MRI scans taken after an 8 week course of mindfulness practice revealed that the amygdala, responsible for fear an emotion, shrank, as the prefrontal cortex, responsible for awareness, concentration, and decision making, became thicker.

Studies in mice demonstrated that when the pre-Botzinger complex was altered (a group of rhythmically firing neurons that affect the speed at which mice breathe each breath) the experimental group of mice with slower breaths were found to be much more calm than their control counterparts. This suggests that the change in breathing alone can help create a meditative calm.

And it's not just mice! Multiple studies with medical students and residents were performed where after adhering to a mindfulness curriculum reported decreased burnout and and increase to their overall wellness.

What are methods of practicing mindfulness?

Multiple different ways- some better suited to be practiced at home, while taking or walk, or more relevant to us- during a busy shift. Here a few examples recommended by the guide:

https://www.emra.org/globalassets/emra/publications/books/emra-wellness-guide/ch1/ch1_exercises_2.png

As my final POTD, I really hope you got something out of this month's emails! Thanks for all the feedback along the way!

-SD

Sources:

https://www.emra.org/books/emra-wellness-guide/ch1.-mindfulness-and-the-emergency-medicine-mind/

https://www.mindful.org/meditation/mindfulness-getting-started/

https://www.takingcharge.csh.umn.edu/what-mindfulness

https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040904/

https://www.emdocs.net/mindfulness-for-physician-wellness-and-even-your-patients/